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Less Blood is Really More, Transfusion Critics Say

As a doctor and a patient, Dale Reisner knows the value of donated blood. But when the Seattle obstetrician had to have heart surgery four years ago, she did everything possible not to get a single drop.

“I don’t have any religious problems with it. If I was near death, I definitely would have taken blood, no question,” said Reisner, who is fine now at age 62. “But if I could avoid a transfusion by better pre-op preparation, then I was interested.”

Long dominated by Jehovah’s Witnesses — whose faith forbids blood transfusions — bloodless surgeries and blood conservation programs are now attracting mainstream patients worried about what some experts say are clear risks, including more infections, longer recuperation, increased illness and even death.

"The best blood is in your own veins,” said Dr. Lori Heller, medical director of the blood management program at Swedish Medical Center in Seattle, where Reisner had her surgery — without any transfusion. “We want to think before we transfuse.”

Decades of experience with Jehovah’s Witness patients, including 1.5 million members in the United States, has helped propel the new emphasis on blood management, said Sherri Ozawa, clinical director of the Institute for Patient Blood Management at Englewood Hospital and Medical Center in New Jersey.

“In the early days, it was, ‘We have Witness patients, what in the world do we do with them?’” she recalled. “Now we believe it should be the standard of care.”

Change in attitudes about blood More doctors, from cardiac surgeons to orthopedists, are offering patients ways to conserve their own blood and avoid transfusions. From drugs that boost blood levels before surgery to cell salvage and blood diversion techniques during operations and lower thresholds for giving blood at all, the techniques are a sea change in the attitude that more blood is always better.

“There’s a movement across the country to use less blood,” said Dr. Marisa Marques, a professor of pathology at the University of Alabama at Birmingham Hospital, who has led a new program that has cut blood use there by at least 25 percent since 2003. At the same time, she said blood costs for the hospital fell by $3.5 million per year.

The number of U.S. hospitals with blood management programs has jumped from about 70 in 2002 to about 110 today. That’s still a fraction of the 5,815 registered hospitals in the country, but others are looking to adopt some of the techniques, said Dr. Darrell Triulzi, a professor of pathology at the University of Pittsburgh and vice president of the board of directors of AABB, an association of blood banks and professionals.

However, Triulzi and other critics caution that while thoughtful blood management is a good goal, the downside of transfusion isn’t as clear-cut as some advocates claim. Some studies have shown negative associations in patients who receive transfusions, but not that the blood caused the problems.

“You can’t tell whether it’s sicker patients that are getting transfused, or whether it’s from the transfusion itself,” he said.

In the U.S., which sucked up 14.4 million units of blood in 2007, blood use has been growing at about 2 percent to 3 percent a year. However, it’s expected to be flat when new figures come out this fall, Triulzi said. Part of that is fueled by the economic downturn, which put a damper on elective surgeries and left fewer patients with health insurance to pay for necessary operations. But part of it is fueled by a philosophical shift, particularly among some doctors.

“I shudder when I think about it,” said Heller, a cardiac anesthesiologist. “We used to just routinely transfuse.”

The shift started in about 1999, when first studies in Canada indicated that patients who got transfusions seemed to do worse than those who didn’t. Since then, the awareness has grown, said Dr. Timothy Hannon, a former Navy flight surgeon who founded Strategic Blood Management, an Indianapolis consulting firm hired by hospitals interested in cutting blood use.

“As our knowledge of transfusions has progressed, we find that transfusions are less beneficial than we once thought and more harmful,” Hannon said.

For some docs, transfusion is a habit Still, many doctors today turn to transfusion as an automatic practice, giving borderline anemic patients smaller amounts of blood — often just one to two units — out of habit, said Hannon, who consulted worked with some 30 hospitals since 2001.

The trouble with that, said Marques, whose hospital hired Hannon, is that every blood transfusion is like a miniature organ transplant, with the potential for reactions, errors and infections.

“Anytime we’re exposed to someone else’s blood, we’re exposed to antibodies we’ve never seen before,” she said. “People think blood is lifesaving, but complications are the price you pay.”

Studies have shown that blood transfusions are associated with higher levels of hospital-related infections, pneumonia and central-line sepsis, a blood infection.